SI Review: September 2013


In Good Hands: Advanced practitioners can fill the gaps

Advanced practitioners can fill the gaps expected from physician shortages

By Sharon Thomas

Note: The article is based on a panel discussion at the 2012 Healthcare Staffing Summit.

The debate about physician supply is an old one. Do we have a surplus or a deficient supply of generalist and specialist physicians? But for the last few years, concerns about physician supply have been made more complicated — and superseded — by the growing concerns about healthcare reform. What are the effects of the Affordable Care Act on the U.S. physician requirement?

In a year and a half, if federal healthcare reform proceeds as expected, roughly 30 million of the estimated 50 million uninsured people in the United States will become insured and will try to find new primary care providers. Meanwhile, the number of people aged 65 and over (and thus eligible for Medicare) will climb. They represented 12.4 percent of the population in the year 2000, and are expected to comprise 19 percent of the population by 2030 — and they, too, will require medical care.

That’s the demand side. The supply side — the number of doctors to care for those people — is another story. Fewer physicians coming out of residency programs are interested in primary care. By 2015, the physician shortage is expected to be 62,900, according to data from the American Academy of Medical Colleges. That number is expected to double by 2025, to a shortage of 130,000.

Filling the Void

Primary care needs can be met by other professionals, however. According to Ryan Kelly, citing a Kaiser Family Foundation study most tasks (83 percent) in a primary care practice can be safely performed by a “mid-level provider,” such as physician assistants or (nurse or advance) practitioners — nurses whose training exceeds that of registered nurses. Kelly is a partner with Shore Capital Partners, a private equity firm that specializes in partnering with midlevel healthcare companies.

These individuals can be an attractive option for healthcare facilities and patients alike. Why?

For starters, nurse practitioners and physician assistants each cost about 50 percent of what primary care physicians earn, according to Bureau of Labor Statistics data. But employment options for them are not equal. While physician assistants fall into the category of mid-level providers, they always work under the supervision of a physician. And because physicians are more unlikely to pursue primary care, so are their assistants.

Nurse practitioners, meanwhile, are able to work without direct supervision of a physician in many states (some states require collaboration, while 17 plus the District of Columbia allow for complete autonomy) and all states allow them to prescribe medications, says Kelly.

And they are more attracted to primary care, adds Cynthia Kinnas, president of Randstad Healthcare. In fact, 75 percent of the 157,000 credentialed nurse practitioners in the U.S. provide primary care, according to the American Association of Nurse Practitioners (AANP).

Because they can operate independently, there is more diversity in where you can find placements for nurse practitioners compared to physician assistants, Kinnas says. Nurse practitioners typically want to shift out of large hospitals and toward outpatient clinics, outpatient centers, urgent care, retail clinics, physician’s offices and smaller non-teaching hospitals. Teaching facilities have access to a lot of residents and physician assistants, so there aren’t as many opportunities for nurse practitioners there.

Rural settings, typically underserved by medical professionals, are also attractive to nurse practitioners. Eighteen percent of practicing nurse practitioners currently serve communities of fewer than 25,000 residents.

And their ranks continue to grow, with graduation rates growing by 70 percent between 2005 and 2010, according to an AANP report.

Attracting Talent, Building Community

While signs point to the growing ranks of advanced practitioners, demand will still be tight. Unemployment for most healthcare specialties, is significantly low — at the low 3 percentage-point range and below, according to May 2012 BLS data, the latest data available Such low numbers makes recruiting particularly challenging. So providers need to be competitive and have a p an for captu ing the attention of candidates and keeping their attention once on board.

“We have to build a community … to enhance the external perception of being an ‘employer of choice ’” says Grace Paranzino, chief clinical officer, Healthcare Products, for Kelly Services. “We have to understand who our ideal candidates are. They (can then) become the target and help us strengthen our messaging and engagement tactics. Understanding their background in education, we can focus our core values as an organization to those ideal candidates, which strengthens our employee value proposition to them.”

And the company’s message must remain succinct and clear for any marketing or outreach strategy. The technology and systems as well should not be getting in the way of the message. Forty percent of those who connect with a brand are doing it on either a smart phone or tablet, so companies need to make sure that the systems are accessible to these devices. “If your online systems aren’t fully functional for your candidates’ mobile devices, they may turn to your competitor instead. Have you gone out and applied for one of the jobs you have posted lately? After your candidates apply, do they hear back from you?” Paranzino asks. It’s important that from the initial contact onward, the candidates have a good experience.

Solid functionality apart, it’s good fresh content that draws them in and has them coming back for more. Experts recommend that you bring employees and candidates into a community of content, with job updates that help them understand the value proposition from day one. Gamification and video are attractive ways to share with potential candidates more about what a company does.

Remember: increased salaries and benefits are no longer enough to keep quality employees happily loyal. In building a talent community, use appropriate messaging and company information to convert them to a new hire. Two-way communication with potential candidates and employees is a must. This way everyone can be a potential candidate or brand ambassador and help spread the word about employment opportunities and offer testimonials and referrals.

Customer relationship management (CRM) tools can help with messaging those who want to receive a company’s messages; social media can help expand a company’s brand.

“The new reality in recruiting is really simple: talent is our competitive advantage and that talent is really scarce,” Paranzino says. “As the demand grows for nurse practitioners and physician assistants, we have to evolve our engagement tactics into a more sophisticated high-end sales/marketing value proposition that starts with the job description and continues even after they have left us, because there is always that hope that they may boomerang and return back to us later in their career.”

Certification Challenges

Talent scarcity isn’t the only challenge staffing firms face in this space.

Tracking certifications can be a challenge when working with advanced practitioners in a travel capacity, Kinnas notes. While nurse practitioners can be nationally certified by the American Nurses Credentialing Center (ANCC) or AANP, not all states recognize it. So the practitioner would need to be certified in each state that does not accept these certifications in order to treat patients there.

Staffing firms would also have to keep track of the collaboration requirements among the states that do not allow for complete autonomy. To complicate matters even further, Kinnas notes, each state has different ideas about what constitutes collaboration or supervision. Add to that the differing regulations with regard to prescribing authority (all allow advanced practitioners to prescribe medicines, but some restrict the type of medicine and a handful require a physician’s collaboration).

So staffing firms would need to ensure not only they are aware of the regulations in the states they place advanced practitioners, but also that their advanced practitioners understand and adhere to the requirements. “Ultimately, staffing firms are accountable from a liability perspective,” Kinnas warns.

It doesn’t stop there. A lot of healthcare facilities have not used contingent advanced practitioners, and may not be aware of the intricacies of their states’ regulations, Kinnas notes, “so it is important that your salespeople and account managers are able to educate them.”

There is also a greater reluctance for physician assistants and nurse practitioners alike to do contract work, says Jeff Bowling, CEO of The Delta Companies. There seems to be some sort of cultural taboo. So staffing firms thinking they can turn to nurse practitioners to meet some of their temporary or travel job orders may have a hard sell. However, in spite of this bias, Bowling notes his recruiters have had great success making perm placements. “We are filling almost two-thirds of the job orders that we get on a perm basis, which is higher than the average for our other allied searches,” he says.

For those nurse practitioners who do accept temporary or travel placements, classification can be a challenge for staffing providers. While they must pass the IRS’ litmus test for independent contractor status, individual states may not agree. Especially on a travel basis, you could send a physician assistant to one state as a 1099 and another as a W-2, which could be risky if the worker attempts to collect unemployment later.

Fee Structure

Despite enjoying high placement rates for physician extender placements, the fee structure for perm placement does not mirror other high-skill segments, Bowling says. In traditional executive search or perm placement, a provider can earn 20 percent to 30 percent of first-year earnings. But healthcare organizations are loathe to pay such rates. Placing a $500,000 a year physician would result in a fee of $30,000 at best. The average fee on a nurse practitioner or physician assistant, including retainer, is $20,000 to $25,000, so the placement fee may be $15,000 to$20,000, Bowling notes.

Despite all the challenges that staffing firms will encounter attracting and placing non physicians, the doctor shortage will shape the new reality. The physician scarcity is expected to worsen over the next decade, healthcare facilities and communities will have to turn to non-physicians to meet primary care needs. Given that fewer physicians are interested in primary care, nurse practitioners are a vital source to meet those needs. Nurse practitioners are an attractive option for all sides of the healthcare equation.

Sharon Thomas is associate editor. She can be reached at


The Matter of Autonomy

The issue of autonomy is a matter of debate within the medical community. The American Medical Association (AMA) is very vocal against nurse practitioners being allowed to practice without supervision as well as prescribe medicine. However, the American Association of Nurse Practitioners (AANP) is lobbying very hard for looser regulations to give nurse practitioners more leeway in some states.

Despite the AMA’s objections, research indicates care provided by nurse practitioners is equal to that provided by physicians, according to the Kaiser Family Foundation. In fact, the foundation noted in a report on Medicaid and the uninsured, “numerous studies show that patients are generally more satisfied with primary care provided by nurse practitioners compared to physician-provided care, and more likely to have been given appropriate advice.”

It’s unlikely nurse practitioners will lose their autonomy, at least in some areas. The Affordable Care Act provides funding to nursing schools to increase the number of nurse practitioners. The legislation also provides funding for the development of nurse-led facilities in medically underserved communities — rural areas that do not typically attract physicians and physician assistants.


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